Lateralizing calcaneal osteotomy performed with a percutaneous burr results in a significantly lower increase in tarsal tunnel pressure.

PURPOSE: Tarsal tunnel syndrome is well documented following lateralizing calcaneal osteotomy to manage varus hindfoot deformity. Traditionally, calcaneal osteotomy is performed with an oscillating saw. No studies have investigated the effect of alternative surgical techniques on postoperative tarsal tunnel pressure. The purpose of this study was to investigate the difference in tarsal tunnel pressures following lateralizing calcaneal osteotomy performed using a high-torque, low-speed "minimally invasive surgery" (MIS) Shannon burr versus an oscillating saw. METHODS: Lateralizing calcaneal osteotomy was performed on 10 below-knee cadaveric specimens. This was conducted on 5 specimens each using an oscillating saw (Saw group) or MIS burr (Burr group). The calcaneal tuberosity was translated 1 cm laterally and transfixed using 2 Kirschner wires. Tarsal tunnel pressure was measured before and after osteotomy via ultrasound-guided percutaneous needle barometer. Mean pre/post-osteotomy pressures were compared between groups. Differences were analyzed using Student's t test. RESULTS: The mean pre-procedure tarsal tunnel pressure was 25.8 ± 5.1 mm Hg in the Saw group and 26.4 ± 4.3 mm Hg in the Burr group (p = 0.85). The mean post-procedure pressure was 63.4 ± 5.1 in the Saw group and 47.8 ± 4.3 in the Burr group (p = 0.01). Change in tarsal tunnel pressure was significantly lower in the Burr group (21.4 ± 4.5) compared to the Saw group (37.6 ± 12.5) (p = 0.03). The increase in tarsal tunnel pressure was 43% lower in the Burr group. CONCLUSION: In this cadaveric study, tarsal tunnel pressure increase after lateralizing calcaneal osteotomy was significantly lower when using a burr versus a saw. This is likely because the increased width ("kerf") of the 3 mm MIS burr, compared to the submillimeter saw blade width, causes calcaneal shortening. Given the smaller increase in tarsal tunnel pressure, using the MIS burr for lateralizing calcaneal osteotomy may decrease the risk of postoperative tarsal tunnel syndrome. Future research in vivo should explore this.

A Case of Short Radiolunate Avulsion Injury: Magnetic Resonance Diagnosis and Surgical Reconstruction.

Injury to the volar wrist capsule with short radiolunate ligament avulsion is uncommon and is often difficult to discern on advanced imaging, which can lead to a delay in diagnosis and the development of chronic wrist instability. We report a case of a short radiolunate ligament avulsion injury and a volar wrist capsular injury that went unrecognized for an extended period and led to chronic wrist pain and instability. We describe the magnetic resonance imaging findings of the injury and detail a successful surgical reconstruction technique.

Outcomes of Total Hip Arthroplasty Via the Direct Anterior vs Alternative Approaches for Acute Femoral Neck Fractures.

BACKGROUND: Total hip arthroplasty (THA) performed for displaced femoral neck fractures (FNF) is becoming a more frequent treatment in the active elderly population. The complication profiles associated with THA surgical approaches in the fracture setting are unclear. The purpose of this study was to compare a series of THA for FNF performed via the direct anterior (DA) approach vs alternative approaches (anterolateral and posterolateral). METHODS: A retrospective review identified 52 patients who underwent primary THA for FNF between 2009 and 2018, including 20 via the DA approach and 32 by alternative approaches. All procedures were exclusively performed by high-volume arthroplasty surgeons. Perioperative results, complications, and clinical outcomes were compared with those of routine statistical methods. Mean follow-up duration was 3 years (range, 1-8). RESULTS: The average age was 74 years (range, 57-92) with similar baseline characteristics between the 2 groups (P = .09). The DA cohort demonstrated significantly shorter length of stay (3 days vs 5 days, P < .01) and discharge to home vs skilled nursing facility (40.0% vs 9.4% P = .014). There was a trend toward decreased complications (0% vs 16%, P = .08). There were no dislocations or fractures in either cohort. Final Harris Hip Scores (94 vs 81, P = .07) and return to community ambulation (96%) were similar between DA and alternative approach groups. CONCLUSION: The DA approach to THA performed for FNF appears safe with improved outcomes compared with alternative approaches. Larger studies are needed to verify these results.

Economic impact of outreach athletic trainers on a health system: implications for program growth and sustainability.

OBJECTIVES: There are numerous benefits of organized athletics, but there is an inherent risk with competitive participation. The need for proper care for high school and community athletes can be met with comprehensive community sports medicine programs, and the employment of certified athletic trainers (AT-Cs). The benefit of clinic-based AT-C has been clearly demonstrated, but there has been little published on the economics of outreach AT-C serving directly in the community. Our hypothesis was that outreach AT-Cs are economically sustainable to an academic health system. METHODS: Evaluation of clinical business generated from the outreach Sports Medicine AT-C program at our institution was performed from fiscal years 2012 to 2015 to determine new referrals, billable patient encounters (bpe), and corresponding revenue generated. Data were retrieved from an existing aggregate business analysis, including both professional billing and hospital billing; data were restricted to the fiscal year of the initial referral. Both new patients and patients with established care were identified. Total revenue was determined, as well as the distribution across clinical departments within our health system. RESULTS: 8570 bpe resulted from 843 patients referred into the system, yielding $2286,733 in total revenue. Of these, 187 were new patients, yielding 1602 bpe. Each patient generated an average of 10.17 bpe, by combining revenue across services; this yielded an average of $2712 per patient generated through the AT-C program. CONCLUSION: Affiliation between a health system and community sports teams through an outreach AT-C program is an economically sustainable, symbiotic relationship. Additionally, there is not only a positive economic impact for sports medicine and orthopaedic providers but also a distinct benefit to the entire health system. This is the first study to demonstrate that an outreach AT-C program is financially sustainable and directly benefits the entire health system across many subspecialties.